JCS/CVIT/JCC 2023 Guideline Focused Update on Diagnosis and Treatment of Vasospastic Angina (Coronary Spastic Angina) and Coronary Microvascular Dysfunction

Hokimoto, Seiji; Kaikita, Koichi; Yasuda, Satoshi; Tsujita, Kenichi; Ishihara, Masaharu; Matoba, Tetsuya; Matsuzawa, Yasushi; Mitsutake, Yoshiaki; Mitani, Yoshihide; Murohara, Toyoaki; Noda, Takashi; Node, Koichi; Noguchi, Teruo; Suzuki, Hiroshi; Takahashi, Jun; Tanabe, Yuji; Tanaka, Atsushi; Tanaka, Nobuhiro; Teragawa, Hiroki; Yasu, Takanori; Yoshimura, Michihiro; Asaumi, Yasuhide; Godo, Shigeo; Ikenaga, Hiroki; Imanaka, Tadayuki; Ishibashi, Keiichiro; Ishii, Masanobu; Ishihara, Takayuki; Matsuura, Yukiko; Miura, Hiroyuki; Nakano, Yukiko; Ogawa, Takayuki; Shiroto, Takashi; Soejima, Hirofumi; Takagi, Ryu; Tanaka, Akihito; Taruya, Akira; Tsuda, Etsuko; Wakabayashi, Kohei; Yokoi, Kensuke; Minamino, T; Nakagawa, Yoshihisa; Sueda, Shozo; Shimokawa, Hiroaki; Ogawa, Hisao

doi:10.1253/circj.cj-22-0779

Cited by 48 publications

(96 citation statements)

References 491 publications

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“…Positive ACh test results were defined as transient total occlusion or focal 90% stenosis of the coronary artery with signs or symptoms of myocardial ischemia (angina pain and ischemic electrocardiogram change) or 90% diffuse vasoconstriction induced in two or more contiguous segments of the coronary artery. [3] CAG was then performed with a coronary injection of at least 1 mg of isosorbide dinitrate for each coronary artery.…”

Section: Study Population and Designmentioning

confidence: 99%

“…Coronary spasm provocation test using acetylcholine (ACh) is the gold standard for diagnosing vasospastic angina (VSA). [1][2][3][4][5] During the ACh test, paroxysmal atrial fibrillation (PAF) is frequently (8.0-22.8%) provoked, is usually transient, and sometimes requires treatment with antiarrhythmic drugs or electrical cardioversion. [6][7][8][9][10] Although PAF during the ACh test is generally recognized as a minor complication, it may have clinical implications.…”

Section: Introductionmentioning

confidence: 99%

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Clinical Implications of Atrial Fibrillation Provoked by Acetylcholine

Shibata,

Wakabayashi,

Ikeda

et al. 2023

Preprint

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Background: The coronary spasm provocation test using acetylcholine (ACh) is useful for diagnosing vasospastic angina (VSA). Paroxysmal atrial fibrillation (PAF) during ACh testing is frequent and usually transient. However, the clinical implications of PAF provoked by ACh is unknown. Deterioration of the left atrial (LA) reservoir strain is associated with new-onset of atrial fibrillation (AF) and fibrosis of the left atrium; additionally, ACh shortens the action potential duration and facilitates AF in the fibrotic atria in the human AF model. Hence, this study aimed to investigate the relationship between LA function and occurrence of AF during the ACh test. Methods: We studied a consecutive cohort of 100 patients (60.1±14.5 years, 39 women) without history of AF who underwent the ACh test in our centers from 2015 to 2022. Echocardiographic data were available for all the patients. PAF was defined as lasting >30 s during the ACh test. Based on the occurrence of AF during the ACh test, the patients were divided into two groups: provoked PAF group (n=29) vs. non AF group (n=71). LA function was assessed via two-dimensional speckle-tracking echocardiography. Occurrences of spontaneous AF were recorded as clinical events during long-term follow-up. Results: The observation period was 675 (114.5-1789.5) days, and 65 patients (65%) were tested positive in the ACh test and diagnosed with VSA. LA volume index was similar between provoked PAF and non AF groups (26.9±7.4 mL/m2 vs. 27.1±8.5 mL/m2, p=0.89). In contrast, LA reservoir (27.6±5.2% vs. 34.8±6.8%, p<0.001) and conduit (13.4±5.1% vs. 18.4±6.2%, p<0.001) strain were significantly lower in provoked PAF group than in non AF group. The provoked PAF group had a lower LA booster strain (14.1±5.6% vs. 16.4±6.3%, p=0.093) than non AF group. A multiple regression analysis showed that LA reservoir strain was independently associated with the provoked PAF during ACh test (OR 0.81, 95% CI: 0.72-0.91, p<0.001). In the provoked PAF group, spontaneous AF occurred in three patients (10.3%), one of whom was treated with pulmonary vein isolation, whereas there were no events of PAF in the non AF group. Conclusion: The occurrence of PAF during the ACh test suggests dysfunction of left atria and may predict future PAF.

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Section: Study Population and Designmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Clinical Implications of Atrial Fibrillation Provoked by Acetylcholine

Shibata,

Wakabayashi,

Ikeda

et al. 2023

Preprint

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“…VA is implicated in various heart diseases including acute coronary syndrome, and fatal arrhythmic events [3,4]. According to the guidelines of the Japanese Society of Cardiology (JCS), the coronary spasm provocation test is the standard diagnostic method [5,6]. The relative prevalence of VA is unclear between Eastern and Western countries, although there is a higher incidence in Korea and Japan [7,8].…”

Section: Introductionmentioning

confidence: 99%

Comparison of clinical outcomes in patients with mixed angina and pure vasospastic angina

Song,

Kim,

Lee

2024

Coronary Artery Disease

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Objective This study investigated differences in clinical outcomes between mixed angina (MA) and pure vasospastic angina (PVA). Methods A total of 524 vasospastic angina patients who did or did not have >50% coronary artery stenosis from January 2005 to January 2021 were divided into two groups (Group 1: PVA, N = 399; Group 2: MA, N = 125) and then three groups [Group 1: PVA, N = 399; Group 2: MA without percutaneous coronary intervention (PCI), N = 67; Group 3: MA with PCI, N = 58] for assessment. We recorded the incidence of major adverse cardiac and cerebrovascular events (MACCE: the composite of death, myocardial infarction, nonfatal stroke or rehospitalization) during 3-year clinical follow-up. Results Compared to the PVA group, there were significant differences in MACCE (20.8% vs. 11.8%, P = 0.011) and rehospitalization (20.0% vs. 9.8%, P = 0.002) in the MA group. Kaplan–Meier analysis showed that patients in the MA with PCI group had the highest cumulative incidence rate of MACCE during the 3-year follow-up (log-rank P < 0.001). Conclusion Compared with the PVA patients, MA patients had significantly worse clinical outcomes during long-term follow-up.

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“…1-3 Because of advancements in comprehending the pathophysiologically complex mechanisms of CMD, and the spread of noninvasive and invasive diagnostic procedures, CMD is being increasingly given attention as a significant contributor to myocardial ischemia among patients presenting with not only microvascular angina, but also obstructive coronary artery disease (CAD), epicardial coronary artery spasm, takotsubo syndrome, cardiomyopathies, and heart failure. [1][2][3] In general, the diagnostic criteria for CMD are: (1) decreased coronary flow reserve as represented by an increased coronary perfusion response to adenosine, (2) coronary microvascular spasm (reproducible chest pain/ discomfort and ischemic ECG changes during spasm provocation test, without epicardial coronary artery spasm), (3) increased index of microcirculatory resistance, and (4) coronary slow-flow phenomenon (TIMI frame count >25). 1 Furthermore, CMD can be classified into 4 types according to the different clinical scenarios: (1) CMD in the absence of myocardial diseases and obstructive CAD, (2) CMD in myocardial diseases, (3) CMD in obstructive CAD, and (4) iatrogenic CMD.…”

mentioning

confidence: 99%

“…[1][2][3] In general, the diagnostic criteria for CMD are: (1) decreased coronary flow reserve as represented by an increased coronary perfusion response to adenosine, (2) coronary microvascular spasm (reproducible chest pain/ discomfort and ischemic ECG changes during spasm provocation test, without epicardial coronary artery spasm), (3) increased index of microcirculatory resistance, and (4) coronary slow-flow phenomenon (TIMI frame count >25). 1 Furthermore, CMD can be classified into 4 types according to the different clinical scenarios: (1) CMD in the absence of myocardial diseases and obstructive CAD, (2) CMD in myocardial diseases, (3) CMD in obstructive CAD, and (4) iatrogenic CMD. 2, 4 The CMD in patients presenting as acute coronary syndrome is categorized as Type 3, and the acute form of CMD is mainly caused by coronary microvascular obstruction (CMVO).…”

mentioning

confidence: 99%